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Andre Monteiro, Gustavo M. Cortez, Muhammad Waqas, Hamid H. Rai, Ammad A. Baig, Rimal H. Dossani, Justin M. Cappuzzo, Faisal Almayman, Amin Aghaebrahim, Jason M. Davies, Eric Sauvageau, Kenneth V. Snyder, Ricardo A. Hanel, Elad I. Levy, and Adnan H. Siddiqui

OBJECTIVE

Acute basilar artery occlusion (BAO) is a rare large-vessel occlusion associated with high morbidity and mortality. Modern thrombectomy with stent retrievers and large-bore aspiration catheters is highly effective in achieving recanalization, but a direct comparison of different techniques for acute BAO has not been performed. Therefore, the authors sought to compare the technical effectiveness and clinical outcomes of stent retriever–assisted aspiration (SRA), aspiration alone (AA), and a stent retriever with or without manual aspiration (SR) for treatment of patients presenting with acute BAO and to evaluate predictors of clinical outcome in their cohort.

METHODS

A retrospective analysis of databases of large-vessel occlusion treated with endovascular intervention at two US endovascular neurosurgery centers was conducted. Patients ≥ 18 years of age with acute BAO treated between January 2013 and December 2020 with stent retrievers or large-bore aspiration catheters were included in the study. Demographic information, procedural details, angiographic results, and clinical outcomes were extracted for analysis.

RESULTS

Eighty-three patients (median age 67 years [IQR 58–76 years]) were included in the study; 33 patients (39.8%) were female. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (IQR 10–21). Intravenous alteplase was administered to 26 patients (31.3%). The median time from symptom onset to groin or wrist puncture was 256 minutes (IQR 157.5–363.0 minutes). Overall, successful recanalization was achieved in 74 patients (89.2%). The SRA technique had a significantly higher rate of modified first-pass effect (mFPE; 55% vs 31.8%, p = 0.032) but not true first-pass effect (FPE; 45% vs 34.9%, p = 0.346) than non-SRA techniques. Good outcome (modified Rankin Scale [mRS] score 0–2) was not significantly different among the three techniques. Poor outcome (mRS score 3–6) was associated with a higher median admission NIHSS score (12.5 vs 19, p = 0.007), a higher rate of adjunctive therapy usage (9% vs 0%, p < 0.001), and a higher rate of intraprocedural complications (10.7% vs 14.5%, p = 0.006). The admission NIHSS score significantly predicted good outcome (OR 0.98, 95% CI 0.97–0.099; p = 0.032). Incomplete recanalization after thrombectomy significantly predicted mortality (OR 1.68, 95% CI 1.18–2.39; p = 0.005).

CONCLUSIONS

The evaluated techniques resulted in high recanalization rates. The SRA technique was associated with a higher rate of mFPE than AA and SR, but the clinical outcomes were similar. A lower admission NIHSS score predicted a better prognosis for patients, whereas incomplete recanalization after thrombectomy predicted mortality.

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Jia Xu Lim, Srujana Venkata Vedicherla, Shu Kiat Sukit Chan, Nishal Kishinchand Primalani, Audrey J. L. Tan, Seyed Ehsan Saffari, and Lester Lee

OBJECTIVE

Malignant internal carotid artery (ICA) infarction is an entirely different disease entity when compared with middle cerebral artery (MCA) infarction. Because of an increased area of infarction, it is assumed to have a poorer prognosis; however, this has never been adequately investigated. Decompressive craniectomy (DC) for malignant MCA infarction has been shown to improve mortality rates in several randomized controlled trials. Conversely, aggressive surgical decompression for ICA infarction has not been recommended. The authors sought to compare the functional outcomes and survival between patients with ICA infarctions and those with MCA infarctions after DC in the largest series to date to investigate this assumption.

METHODS

A multicenter retrospective review of 154 consecutive DCs for large territory cerebral infarctions performed from 2005 to 2020 were analyzed. Patients were divided into ICA and MCA groups depending on the territory of infarction. Variables, including age, sex, medical comorbidities, laterality of the infarction, preoperative neurological status, primary stroke treatment, and the time from stroke onset to DC, were recorded. Univariable and multivariable analyses were performed for the clinical exposures for functional outcomes (modified Rankin Scale [mRS] score) on discharge and at the 1- and 6-month follow-ups, and for mortality, both inpatient and at the 1-year follow-up. A favorable mRS score was defined as 0–2.

RESULTS

There were 67 patients (43.5%) and 87 patients (56.5%) in the ICA and MCA groups, respectively. Univariable analysis showed that the ICA group had a comparably favorable mRS (OR 0.15 [95% CI 0.18–1.21], p = 0.077). Inpatient mortality (OR 1.79 [95% CI 0.79–4.03], p = 0.16) and 1-year mortality (OR 2.07 [95% CI 0.98–4.37], p = 0.054) were comparable between the groups. After adjustment, a favorable mRS score at 6 months (OR 0.17 [95% CI 0.018–1.59], p = 0.12), inpatient mortality (OR 1.02 [95% CI 0.29–3.57], p = 0.97), and 1-year mortality (OR 0.94 [95% CI 0.41–2.69], p = 0.88) were similar in both groups. The overall survival, plotted using the Cox proportional hazard regression, did not show a significant difference between the ICA and MCA groups (HR 0.581).

CONCLUSIONS

Unlike previous smaller studies, this study found that patients with malignant ICA infarction had a functional outcome and survival that was similar to those with MCA infarction after DC. Therefore, DC can be offered for malignant ICA infarction for life-saving purposes with limited functional recovery.

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Joshua S. Catapano, Kavelin Rumalla, Visish M. Srinivasan, Candice L. Nguyen, Dara S. Farhadi, Brandon Ngo, Caleb Rutledge, Redi Rahmani, Jacob F. Baranoski, Tyler S. Cole, Ashutosh P. Jadhav, Andrew F. Ducruet, and Felipe C. Albuquerque

OBJECTIVE

The incidence and severity of stroke are disproportionately greater among Black patients. In this study, the authors sought to examine clinical outcomes among Black versus White patients after mechanical thrombectomy for stroke at a single US institution.

METHODS

All patients who underwent mechanical thrombectomy at a single center from January 1, 2014, through March 31, 2020, were retrospectively analyzed. Patients were grouped based on race, and demographic characteristics, preexisting conditions, clinical presentation, treatment, and stroke outcomes were compared. The association of race with mortality was analyzed in multivariable logistic regression analysis adjusted for potential confounders.

RESULTS

In total, 401 patients (233 males) with a reported race of Black (n = 28) or White (n = 373) underwent mechanical thrombectomy during the study period. Tobacco use was more prevalent among Black patients (43% vs 24%, p = 0.04), but there were no significant differences between the groups with respect to insurance, coronary artery disease, diabetes, illicit drug use, hypertension, or hyperlipidemia. The mean time from stroke onset to hospital presentation was significantly greater among Black patients (604.6 vs 333.4 minutes) (p = 0.007). There were no differences in fluoroscopy time, procedural success (Thrombolysis in Cerebral Infarction grade 2b or 3), hospital length of stay, or prevalence of hemicraniectomy. In multivariable analysis, Black race was strongly associated with higher mortality (32.1% vs 14.5%, p = 0.01). The disparity in mortality rates resolved after adjusting for the average time from stroke onset to presentation (p = 0.14).

CONCLUSIONS

Black race was associated with an increased risk of death after mechanical thrombectomy for stroke. The increased risk may be associated with access-related factors, including delayed presentation to stroke centers.

Free access

Sandeep Kandregula, Amey R. Savardekar, Pankaj Sharma, Jerry McLarty, Jennifer Kosty, Krystle Trosclair, Hugo Cuellar, and Bharat Guthikonda

OBJECTIVE

A paradigm shift in the management of acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) occurred after 2015 when 7 randomized controlled trials demonstrated better outcomes using second-generation thrombectomy devices combined with best medical management than did stand-alone intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA). All recently published landmark trials were designed to study the outcome of mechanical thrombectomy (MT); therefore, the majority of the patients enrolled in these trials received intravenous tPA. Currently, initiating IVT before MT is a matter of debate. Recent trials (DIRECT-MT, DEVT) exploring this clinical question showed noninferiority of MT alone compared with the combined treatment. With this uncertainty, the authors aimed to explore real-world data through the latest National Inpatient Sample (NIS) to compare the safety and outcomes of MT alone with bridging IVT and MT in AIS due to LVO in the middle cerebral artery (MCA).

METHODS

NIS data from 2017 to 2018 were analyzed to compare the outcomes and safety profiles of patients who underwent MT+IVT with those who underwent MT alone.

RESULTS

A total of 2895 patients were included in the final analysis (MT, n = 1669; MT+IVT, n = 1226). The mean National Institutes of Health Stroke Scale score was 16.2 (SD 6.1) in the MT group and 16.6 (SD 5.97) in the MT+IVT group (p = 0.04). With respect to comorbidities, the two groups did not differ in rates of hypertension (p = 0.730), atrial fibrillation/flutter (p = 0.828), and smoking status (p = 0.914). The rate of diabetes mellitus was significantly higher in the MT group (28%) than in the MT+IVT group (22.1%) (p < 0.001). The frequency of intracerebral hemorrhage (ICH) in the MT group was 17.7% (n = 296) and 21.5% (n = 263) in the MT+IVT group (p = 0.012). Intraventricular hemorrhage (p = 0.875), subarachnoid hemorrhage (p = 0.99), and vasospasm (p = 0.976) did not differ significantly between the groups. The primary outcome considered was disability status between the groups; 23.8% of patients in the MT+IVT group had minimal disability versus 18.2% in the MT group (p = 0.001). The risk of progressing to severe disability from minimal disability decreased with the addition of IVT to MT (OR 0.762, 95% CI 0.637–0.912). The adjusted odds ratio for ICH in the MT+IVT group was 1.28 (95% CI 1.043–1.571, p = 0.018) and 2.676 (95% CI 1.259–5.686, p = 0.01) for access-site hemorrhages.

CONCLUSIONS

In the analysis of the NIS database, the MT+IVT group had significantly higher rates of minimal disability at the time of hospital discharge versus the MT-alone group, despite a higher rate of ICH. The question of whether to treat patients with MT+IVT rather than MT alone is currently being addressed in ongoing prospective clinical trials (SWIFT-DIRECT [NCT03494920], MR CLEAN–NO IV [ISRCTN80619088], and DIRECT-SAFE [NCT03494920]). The results of these studies will contribute to greater understanding and progressive improvement in outcomes for AIS patients.

Free access

Roberta K. Sefcik, Daniel A. Tonetti, Shashvat M. Desai, Stephanie M. Casillo, Michael J. Lang, Ashutosh P. Jadhav, and Bradley A. Gross

OBJECTIVE

Acute basilar artery occlusion (BAO) harbors a more guarded prognosis after thrombectomy compared with anterior circulation large-vessel occlusion. Whether this is a function of a greater proportion of atherosclerotic/intrinsic lesions is not well studied. The authors aimed to elucidate the prevalence and predictors of intracranial intrinsic atherosclerotic disease in patients with acute BAO and to compare angiographic and clinical outcomes between patients with BAO secondary to embolic versus intrinsic disease.

METHODS

A prospectively maintained stroke database was reviewed for all patients presenting between January 2013 and December 2019 to a tertiary care academic comprehensive stroke center with acute, nontandem BAO. Patient data were extracted, subdivided by stroke mechanism and treatment modality (embolic [thrombectomy only] and intrinsic [thrombectomy + stenting]), and angiographic and clinical results were compared.

RESULTS

Of 107 patients, 83 (78%) had embolic occlusions (thrombectomy only) and 24 (22%) had intrinsic disease (thrombectomy + stenting). There was no significant difference in patient age, presenting National Institutes of Health Stroke Scale score, time to presentation, selected medical comorbidities (hypertension, hyperlipidemia, diabetes, and atrial fibrillation), prior stroke, and posterior circulation Alberta Stroke Program Early CT Score. Patients with intrinsic disease were more likely to be active smokers (50% vs 26%, p = 0.04) and more likely to be male (88% vs 48%, p = 0.001). Successful recanalization, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2b or 3, was achieved in 90% of patients and did not differ significantly between the embolic versus intrinsic groups (89% vs 92%, p > 0.99). A 90-day good outcome (modified Rankin Scale [mRS] score 0–2) was found in 37% of patients overall and did not differ significantly between the two groups (36% vs 41%, p = 0.41). Mortality was 40% overall and did not significantly differ between groups (41% vs 36%, p = 0.45).

CONCLUSIONS

In the current study, demographic and clinical results for acute BAO showed that compared with intrinsic disease, thromboembolic disease is a more common mechanism of acute BAO, with 78% of patients undergoing thrombectomy alone. However, there was no significant difference in revascularization and outcome results between patients with embolic disease and those with intrinsic disease.

Open access

John Muse, Luke Silveira, Adam Olszewski, Erin D’Agostino, Bruce Tranmer, and Brandon Liebelt

Epidermoid cysts of the pineal region are a rare entity. Herein, the authors describe the endoscopic resection of a recurrent pineal region epidermoid by way of a supracerebellar infratentorial approach. The patient was positioned in the semiseated upright position with head tilted to the right and slightly flexed, maximizing gravity-based cerebellar retraction, and a paramedian craniotomy was performed owing to the gradual flattening of the tentorium from medial to lateral. This setup, in tandem with the enlarged viewing window achieved by use of 0°, 30°, and 70° endoscopes, afforded the necessary access to achieve a satisfactory resection through this anatomical corridor.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2131.

Open access

Daniel A. Donoho and Guillermo Aldave

Pineal region tumors represent a formidable challenge to the neurosurgeon. Choosing the right approach is key to optimizing the extent of resection and minimizing surgical morbidity. In this video, the authors show an interhemispheric transcallosal approach to a pineal region tumor in a 15-year-old boy. The advantage of this corridor over posterior approaches is that it provides a nice view of the tumor plane with the venous complex, especially while dissecting tumor from the anterior aspect of the internal cerebral veins on their vertical path. Thus, this approach represents a safe and effective alternative for selected pineal tumors.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2120.

Open access

Giuseppe Cinalli, Maria Rosaria Scala, Alessandra Marini, Alessia Imperato, Giuseppe Mirone, and Pietro Spennato

In this video, the authors present an interhemispheric transcallosal transchoroidal approach to a pineal mass in a 15-year-old boy. He received emergency endoscopic third ventriculostomy (ETV), then an endoscopic biopsy that revealed an immature teratoma. Surgical removal was selected. The mass was located very high in the posterior third ventricle, hidden behind the splenium of the corpus callosum and the vein of Galen, so an interhemispheric transcallosal approach followed by a complete dissection of the whole choroidal fissure was chosen and allowed complete removal of the tumor. Microsurgical dissection is presented, showing clearly in detail all the neurovascular structures encountered.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2126.